What it is
A claim rejection happens when a health insurer declines to pay, in full or in part, for a hospital bill or treatment you submitted. The reasons usually trace back to the terms of the policy and to what you told the insurer when you bought it.
The Insurance Regulatory and Development Authority of India (IRDAI) publishes guidance for policyholders that shows where disputes tend to start. This guide uses that guidance. It does not cover any specific insurer or plan.
How it works
Where claims run into trouble
IRDAI’s dos and don’ts for health insurance ask buyers to read several terms closely, because each can limit what is paid:
- Pre-existing disease clause: an exclusion for conditions you already had when buying the policy.
- Waiting period: a stretch of time before certain diseases can be covered.
- Limits on hospitalisation expenses: restrictions or caps on various costs of a stay.
- Co-payment: you share a part of the claim yourself.
- Renewal conditions and age limits: pre-conditions for renewal and upper age limits at entry and at renewal.
Two behaviours are flagged as risky. One is concealing facts: IRDAI warns this can lead to a dispute at the time of a claim. It asks buyers to disclose all pre-existing problems, including major ailments and conditions such as high blood pressure or diabetes. The other is a gap in renewal. IRDAI says even a one-day gap can leave cover insufficient or useless.
It also advises paying the premium only after the insurer accepts your proposal, and complying with documentation and medical test requirements.
The appeal route
IRDAI’s complaint pages set out a sequence:
- Complain to your insurer’s grievance channel first. Put the complaint in writing with the necessary supporting documents.
- If it is not resolved within two weeks, or you are not satisfied with the resolution, approach the Grievance Redressal Cell of IRDAI’s Policyholder’s Protection and Grievance Redressal Department.
You can reach the Cell through IRDAI’s online portal, Bima Bharosa (bimabharosa.irdai.gov.in), by email to complaints@irdai.gov.in, or on the toll-free numbers 155255 or 1800 4254 732. A physical letter can be sent to the General Manager of the department at IRDAI’s office in Nanakramguda, Gachibowli, Hyderabad-500032.
Complete the complaint registration form fully. IRDAI says it cannot register a complaint without the required information.
Why it matters now
Bima Bharosa, earlier known as the Integrated Grievance Management System, was launched in 2022. IRDAI describes it as a central record of industry-wide grievance data and a tool to monitor how insurers handle complaints. A complaint filed there flows to the insurer’s system and to IRDAI’s records, and status updates are mirrored in both.
The system sets target turnaround times, measures the actual time taken and raises alerts when tasks near the limit. After you register, you get a confirmation email with an IRDAI token number that lets you track the complaint.
What it means for you
Before buying or renewing, check the exclusions, waiting periods, co-payment and expense limits in writing, and disclose your health history fully. Keep renewal dates in view so there is no lapse.
If a claim is rejected, file a written complaint with the insurer and keep copies of every document. If you are unable to reach the insurer directly, the Bima Bharosa portal can act as a gateway to register the complaint with the insurance company. Note that IRDAI’s Cell does not accept complaints filed by advocates, agents or other third parties on your behalf. Only the insured or the claimants can complain.
For NRIs buying overseas health cover, IRDAI’s overseas policy guidance asks for the same disclosure and documentation, and to check what the policy covers, including travel risks such as loss of passport, cash or baggage and repatriation expenses.
